Faculty Bibliography

BACKGROUND:Uncorrected superior glenoid wear in patients managed with reverse total shoulder arthroplasty (rTSA) can result in increased complications, including baseplate failure. The present study quantifies the clinical and radiographic outcomes of patients with Favard type-E1, E2, and E3 glenoid deformity who were managed with rTSA with use of a superior or superior/posterior augmented glenoid baseplate. METHODS:We retrospectively reviewed the records for 68 patients with shoulder arthritis and Favard type-E1, E2, or E3 glenoid deformity who were managed with primary rTSA and a 10° superior augmented or 10° superior/8° posterior augmented baseplate. The mean duration of follow-up was 40 months (range, 24 to 85 months). Outcomes were assessed preoperatively and at the latest follow-up with shoulder range of motion and use of outcome scores including the Simple Shoulder Test (SST), University of California Los Angeles (UCLA) score, American Shoulder and Elbow Surgeons (ASES) score, Constant score, and Shoulder Pain and Disability Index (SPADI) score. Radiographs were evaluated preoperatively and at the time of the latest follow-up. Differences in preoperative and postoperative range of motion and outcome metrics were assessed with use of a 2-tailed Student t test. RESULTS:The majority of patients experienced clinically meaningful improvements in terms of pain and function following rTSA with a superior or superior/posterior augment, with 94% of patients rating themselves as "much better" (73.5%) or "better" (20.5%) at the time of the latest follow-up. At least 88% of the patients exceeded the minimum clinically important difference (MCID) threshold, and 75% of patients exceeded the substantial clinical benefit (SCB) threshold, for each of the clinical outcome metrics and range of motion. Five complications were reported (prevalence, 7.4%), including acromial stress fracture (2 patients), posttraumatic scapular neck fracture (1 patient), chronic shoulder pain (1 patient), and aseptic glenoid loosening (1 patient). CONCLUSIONS:The present short-term clinical and radiographic study demonstrated that shoulder arthropathy with superior glenoid wear patterns (Favard types E1, E2, and E3) can be successfully treated with rTSA with a superior or superior/posterior augmented baseplate. Longer-term clinical and radiographic follow-up is necessary to confirm that these promising short-term results are durable. LEVEL OF EVIDENCE/METHODS:Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Little research has been conducted evaluating surgical trends during the past 10 years and subsequent procedure risk factors for patients undergoing bone-blocking procedures for the treatment of anterior shoulder instability. The Statewide Planning and Research Cooperative System database was queried between 2003 and 2014 to identify patients undergoing soft tissue or bone-blocking procedures for anterior shoulder instability in New York. Patient demographics and 1-year subsequent procedures were analyzed. Multivariate logistic regression analyses were conducted to identify 1-year subsequent procedure risk factors. From 2003 through 2014, a total of 540 patients had Latarjet procedures performed. During this period, the volume of Latarjet procedures increased by 950%, from 12 procedures in 2003 to 126 procedures in 2014. The volume of open Bankart repairs declined by 77%; arthroscopic Bankart repairs fluctuated, being up (328%) between 2003 and 2012 and then down (6%) between 2012 and 2014. Of the 540 patients, 2.4% (13 of 540) required intervention for recurrent shoulder instability events. Age older than 20 years and workers' compensation were identified as independent risk factors for reoperation. The number of bone-blocking procedures, such as the Latarjet, has increased by nearly 1000% during the past decade in New York. Only 2.4% (13 of 540) of the patients had subsequent shoulder instability interventions. [Orthopedics. 201x; xx(x):xx-xx.].

Glenohumeral arthritis has become increasingly prevalent. For patients with glenohumeral arthritis and an intact rotator cuff, an anatomic total shoulder arthroplasty (TSA) has been shown to provide substantial pain relief with consistent, reproducible results. The primary indication is intractable pain that has not responded to nonoperative treatment, resulting in a substantial negative impact on the quality of life of the patient. Other indications for anatomic TSA include posttraumatic glenohumeral arthritis, inflammatory arthritis, and humeral head osteonecrosis. Contraindications include active infection, deltoid insufficiency, severe glenoid bone deficiency, and excessive glenohumeral posterior subluxation or laxity that cannot be surgically corrected. In order to provide the stability necessary to withstand the forces that impact the glenoid, the implant used in TSA should replicate the native anatomy of the individual patient by using a combination of implant modularity with different humeral neck angles and glenoid version augments, as well as dual eccentricity of the neck and head implant. The major steps in TSA include (1) preoperative planning, (2) patient positioning and setup, (3) surgical exposure, (4) accessing the glenohumeral joint, (5) preparation of the humerus, (6) exposure and preparation of the glenoid with component insertion, (7) humeral component insertion and trial reduction, (8) subscapularis reattachment and closure, and (9) postoperative immobilization and rehabilitation. The expected outcomes of TSA include improved quality of life (as indicated by improved outcome and patient satisfaction scores), shoulder active range of motion, and strength. In a large study examining outcomes of TSA in patients >55 years old, Patel et al.¹ reported improved American Shoulder and Elbow Surgeons (48.3 ± 23.0), Constant (33.1 ± 16.7), and University of California Los Angeles (16.7 ± 6.3) shoulder scores, as well as improved active range of motion in active abduction (42° ± 41°), forward flexion (46° ± 40°), external rotation (33° ± 23°), and internal rotation (2.2° ± 1.8°) and decreased visual analog scale scores (-5.1 ± 2.9). Another study² showed increased maximal weight improvement of 7.7 ± 4.0 lbs (3.5 ± 1.8 kg).

PURPOSE/OBJECTIVE:Coracoid fracture is a rare injury. The aim of this study is to present the demographics, clinical and radiologic characteristics, and outcomes of coracoid fracture in a cohort of 32 patients. METHODS:We queried our institutional electronic medical record database (years 2012-2020) to identify patients with coracoid fractures using specific International Classification of Disease-10 codes. Demographic data, injury details including mechanism of injury and associated injuries, imaging performed, and treatment outcomes were obtained from retrospective chart review. A radiologist reviewed all available imaging studies (radiographs/CT/MRI) and classified the fractures according to Ogawa and Eyres classifications. Missed diagnoses were determined by comparing initial imaging reports with the follow-up imaging obtained in the office. RESULTS:Thirty-two patients with coracoid fractures were identified during the study period. Sixteen fractures (50%) occurred in the setting of low-energy trauma. Twelve fractures were missed on initial radiographs, and diagnosis with three-view radiographs (AP, scapular-Y and axillary) was 88% compared to 33% (p < 0.03) with two views (AP, scapular-Y). The majority of fractures were non-displaced (94%), and 56% were Ogawa Type-II fractures. Associated injuries were seen in 81% of patients. Most fractures (94%) were treated without surgery with excellent outcomes. CONCLUSION/CONCLUSIONS:Coracoid fractures continue to be a rare injury. In contrast to previous studies, in this case series of 32 patients, half of the fractures were associated with low-energy trauma, which correlated with higher percentage of non-displaced fractures and Ogawa Type-II fractures. Addition of the axillary view in the trauma radiographic series significantly improved the initial fracture detection rate. LEVEL IV/UNASSIGNED:Retrospective study.

OBJECTIVE:To compare MRI with 3D reconstructions and 3D-CT with respect to assessment of glenoid wear in osteoarthritic shoulders. METHODS:3D reconstructions were generated for CT and MR (utilizing the Dixon technique) imaging performed on 29 osteoarthritic shoulders. Two reviewers independently performed glenoid morphometric measurements and evaluated glenoid erosion. Mean differences between the two modalities were calculated. Inter-observer agreement was calculated using kappa coefficient. RESULTS:The combined mean absolute difference (bias) in glenoid version between 3D-CT and 3D-MRI was 2.7° ± 1.6° (range 0.15-7.85, P value = 0.7). The combined mean absolute difference in glenoid inclination between 3D-CT and 3D-MRI was 6.8° ± 4.1° (range 0.8°-15.75°, P value = 0.17). No significant inter-reader variation in glenoid version and inclination measurements on 3D-CT and 3D-MRI was found (P > 0.05). The inter-reader reliability for both CT and MRI was high for Walch grading of glenoid bone loss (κ = 1, κ = 0.81, respectively). CONCLUSIONS:3D-MRI is comparable to 3D-CT with respect to axial glenoid bone loss, as measured by glenoid version. However, for coronal bone loss estimation, measured by glenoid inclination, 3D-CT remains the gold standard. Thus, 3D-MR can be used as an alternative for preoperative assessment of glenoid version in arthritic shoulders.

INTRODUCTION/BACKGROUND:The purpose of this study is to compare the 90 day complication rates of primary Total Elbow Arthroplasty (TEA) performed for arthritis (primary-OA; rheumatoid arthritis-RA) versus those performed for distal humerus fractures (DHF). METHODS:Patients who underwent a TEA from 2015 to 2021 were identified from our institutional database and placed into cohorts based on surgical indications (TEA-OA, TEA-RA and TEA-DHF). Chart review was conducted to analyze the prevalence of complications, emergency department (ED) visits, readmissions, and secondary procedures in the first 90 day post-operative period. Complications included but were not limited to wound complications, hematoma, infection (superficial or deep), nerve palsy, periprosthetic fracture/failure and others. RESULTS:49 patients who underwent TEA were included in this study: (DHF = 19, OA = 14, RA = 16). Six complications occurred within the first 90 days of surgery. There were two periprosthetic joint infections (PJI) in the OA group, requiring irrigation and debridement (I & D) within the first 90 days of surgery. There were three post-operative ulnar nerve palsies and one PJI requiring I & D in the TEA-RA group. Compared to the TEA-DHF and TEA-OA groups, the RA group had higher rates of all-cause complications (p = 0.03) and nerve palsy (p = 0.03). There were no significant differences between groups in readmissions (p = 0.27) or secondary interventions (p = 0.27). CONCLUSION/CONCLUSIONS:The 90-day complication/readmission rates of TEA preformed for DHFs is lower than those preformed for OA and RA. These differences could be related to the underlying chronic inflammatory etiology and side effect of treatments (intraarticular steroid injection, and biologics) received by patients with arthritis. LEVEL OF EVIDENCE/METHODS:Retrospective Cohort Study, level IV.

INTRODUCTION/BACKGROUND:The purpose of this series is to report on the one-year clinical outcomes of instability related anterior glenoid fractures treated with open repair utilizing the subscapularis split technique. METHODS:Patients with displaced anterior glenoid fractures who underwent open surgical treatment via deltopectoral incision and subscapularis split were identified from a single surgeons database. Fractures were repaired using screw fixation or with distal tibia osteochondral allograft reconstruction. Patient Reported Outcome Measurement Information System (PROMIS) Upper Extremity Computer Adaptive Test (UE), PROMIS Pain interference (PI), PROMIS pain intensity (Pi), American Shoulder and Elbow Surgeons (ASES), Visual Analog Scale (VAS) pain, and Subjective Shoulder Value (SSV) scores were obtained at minimum one-year follow-up. RESULTS:Twelve patients with a mean age of 54 (range 28-72) years were included in our study with a follow-up at an average of 16.6 (range 12-30) months. Ten patients underwent internal fixation and two patients underwent allograft reconstruction. Postoperative imaging (n = 10) at latest follow-up demonstrated healed fractures without any hardware complication. Mean postoperative range of motion included forward elevation of 147 ± 44.0° and external rotation of 44 ± 17°. Postoperative PROMs were obtained from nine patients with a mean PROMIS UE, PI, and Pi score of 49.4 ± 4.1, 39.9 ± 3.8 and 35.6 ± 4.3, respectively. The respective mean ASES, VAS, and SSV scores were 91.8 ± 7.2, 1.2 ± 1.0, and 91.0 ± 8.0. CONCLUSION/CONCLUSIONS:Open surgical repair of anterior glenoid fractures utilizing subscapularis split results in good functional outcomes and low complications including risk of recurrent instability. LEVEL OF EVIDENCE/METHODS:III case series.

INTRODUCTION/BACKGROUND:Since the introduction of the Grammont style reverse total shoulder arthroplasty (RTSA), the humeral stem design has been modified with improved clinical outcomes. Two distinct humeral designs have been utilized extensively: the inlay where the humeral tray is seated within the metaphysis and the onlay design where the humerus tray sits on the metaphysis at the level of the humeral neck cut. The purpose of this systematic review is to determine if there are differences in clinical outcomes and complication rates between these designs. METHODS:The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform this systematic review. A search was performed on Medline, PubMed, and Embase to identify all studies comparing clinical results of both humeral designs. Primary outcomes included patient-reported outcomes measures (PROMs), shoulder range of motion, and incidence of complications. RESULTS:From the 156 identified publications, 12 studies were included in the final review. A total of 1447 patients were included with a minimum follow-up of 12 months. At final follow-up, both implants demonstrated significant improvements in comparison to preoperative baseline. When comparing inlay versus onlay groups, the American Shoulder and Elbow Surgeons (ASES) score was higher in the inlay group (mean difference of 2.53 [95% CI: 0.27-4.78] p=0.03). Postoperative motion, even if statically greater in the onlay group (difference in forward flexion 5°(p<0.001), abduction 3° (p=0.003) and external rotation 4°(p<0.001)) are not clinically different. When comparing complications, the inlay group reported more instances of scapular notching (93/322 versus 70/415, OR 0.35 p<0.001) but fewer scapular spine fractures (26/727 versus 21/559, p=0.09). DISCUSSION/CONCLUSIONS:Inlay and onlay humeral tray designs in reverse total shoulder arthroplasty demonstrate similar clinical improvements postoperatively. The onlay implants have low rate of scapular notching but higher rate of scapular spine fracture. Understanding the strength and weaknesses of the two humeral tray designs is important to provide surgeons with options to tailor surgical plan for high risk patients.

Background/UNASSIGNED:The purpose of this study is to report the outcomes in patients undergoing arthroscopic tuberoplasty for symptomatic irreparable rotator cuff tear (RCT). Methods/UNASSIGNED:This is a retrospective cohort study comparing preoperative and postoperative data of patients undergoing arthroscopic tuberoplasty for symptomatic irreparable RCT. Exclusion criteria included open tuberoplasty, concomitant partial RCT repair, glenohumeral arthritis, concomitant ipsilateral extremity fractures, <12 months follow-up, or pseudoparalysis. Demographics, shoulder range of motion (ROM), RCT morphology, re-operation rates, satisfaction and outcome scores were collected from medical records and questionnaires. Outcome scores included Patient Reported Outcome Measurement Information System Upper Extremity (PROMIS), American Shoulder and Elbow Surgeons score (ASES), Subjective Shoulder Value (SSV), and pain Visual Analog Score (VAS). Results/UNASSIGNED:= .0029). Pre- and post-operative ROM were unchanged. There were 4 failures requiring revision. The remaining 17 patients reported high satisfaction scores (3.4 ± 0.7) and 15 (88.2%) answered "yes" to getting the procedure again, with 3/4 failures stating they would also undergo arthroscopic tuberoplasty again. Conclusion/UNASSIGNED:Arthroscopic tuberoplasty demonstrates high levels of satisfaction and pain reduction in symptomatic irreparable RCT. In appropriately indicated patients, this treatment should be considered prior to other salvage options.

Background/UNASSIGNED:The purpose of our study was to examine the clinical outcomes after arthroscopic scapulothoracic bursectomy for the treatment of scapulothoracic bursitis at a minimum of 2-year follow-up. Methods/UNASSIGNED:values <.05 were considered significant. Results/UNASSIGNED: < .05) postoperatively. There was no significant difference in shoulder range of motion after surgery. The mean patient satisfaction was 72.9, with 65% (13/20) of patients reporting satisfaction levels ≥ 80%. Two patients did not report the resolution of their symptoms and required revision surgery. Conclusion/UNASSIGNED:Arthroscopic treatment of scapulothoracic bursitis is a safe, reliable technique that is effective in providing symptomatic relief with a low rate of recurrence, with most patients reporting a significant reduction in periscapular pain.